CSI 101 Skills Lab 3

Emergency Assessment of

Vital Signs and Pain

Daryl P. Lofaso, M.Ed, RRT

Vital Signs (VS)

Temperature Pulse Respiration Blood Pressure Pain Assessment

General Guidelines When Assessing VS Taken by person caring for

patient. Know normal ranges

Adult vs. Peds

Baseline data for patient i.e. patients norms

Patient’s Diagnosis (Dx)

Body Temperature

Balance of Body Temperature

Temperature Conversion

Pulse (Heart Rate – HR) Normal Range (Adult)

60-100/min.

Abnormal < 60/min. - Bradycardia > 100/min. - Tachycardia

Arterial Pulse Points

Abnormal Pulse Characteristics

Weak Pulse – ↓ stroke volume Bounding Pulse - ↑ stroke

volume Paradoxical Pulse – change

with respirations

Respiratory Rate

Normal relaxed breathing is effortless, automatic, regular and even.

Normal range: Adult : 12-20/min.

Child: 20-30/min. Infant: 35-40/min.

Respiratory Patterns

Blood Pressure

B/P = Systolic Pressure / Diastolic Pressure

Systolic Pressure: max. pressure exerted on the arteries with the LV

Diastolic Pressure: the elastic recoil pressure presented by the arterial walls

BP Formulas

Pulse Pressure = systolic pressure – diastolic pressure

Normal: 30-50 mmHg

Mean Arterial Pressure = systolic pressure + 2(diastolic pressure) / 3

Normal: 70-100 mmHg

Shock Index (SI)

Define: the ratio of the heart rate to systolic blood pressure.

SI = HR (bpm) / Systolic B/P (mmHg) Normal range: 0.5 – 0.7 Elevated SI: > 0.9 - critically ill (poor

outcome)

Sensitive indicator of Left Ventricular dysfunction

Used in the Emergency Department (ED) and Intensive Care Unit (ICU)

Pain Assessment

Range:

Mild: 1 – 3

Moderate: 4 – 6

Severe Pain: 7 - 10

Pain Management

Non-Pharmacologic Breathing - slowly and deeply Distraction

Pharmacologic Non-Narcotic

TylenolIbuprofen

NarcoticMorphine

Hand Hygiene

GOOD HAND WASHING CAN PREVENT NOSOCOMIAL INFECTIONS

35% OF NOSOCOMIAL INFECTIONS ARE PREVENTABLE!!!!

Professional Conduct Introduce yourself Explain the procedure /

examination to the patient Ask the patient if they have any

questions Cover the patient with a sheet.

Only expose area examining while performing a procedure/examination